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BACKGROUND AND AIM It is unclear whether second-generation narrow-band imaging (NBI) improves colorectal adenoma detection in clinical practice. We aimed to evaluate the ability of NBI to detect adenomas in academic and community hospitals. METHODS This observational, multicenter study was conducted in four academic and four community hospitals between July 2018 and April 2019. We enrolled patients aged ≥ 20 years who underwent colonoscopy for screening, polyp surveillance, or diagnostic workup. The primary endpoint was the adenoma detection rate (ADR) between NBI (NBI group) and white-light imaging colonoscopies (WLI group) after propensity score (PS) matching. RESULTS Of 1831 patients analyzed before PS matching, the NBI and WLI groups included 742 and 1089 patients, respectively. After PS matching, 711 pairs from both groups were analyzed. ADR and the mean number of adenomas per patient did not differ significantly between the NBI and WLI groups (43.5% vs 44.4%, P = 0.71; 0.90 ± 1.38 vs 0.91 ± 1.40, P = 0.95, respectively). Academic hospitals showed higher ADR in the NBI group (60.5% vs 53.8%), whereas community hospitals showed higher ADR in the WLI group (35.8% vs 40.5%). In the NBI group, ADR was significantly higher among NBI-screening-experienced endoscopists than among NBI-screening-inexperienced endoscopists (63.2% vs 39.2%, P

Two huge earthquakes struck Kumamoto, Japan, in April 2016, forcing residents to evacuate. Few studies have reported early-phase disease and injury trends among evacuees following major inland earthquakes. We evaluated the trends among evacuees who visited a medical clinic in a shelter located at the epicenter of the 2016 Kumamoto earthquakes. The clinic opened on April 15, the day after the foreshock, and closed 3 weeks later. We reviewed medical charts related to 929 outpatient visits and conducted descriptive analyses. The evacuees experienced mild injuries and common diseases. The types of diseases changed weekly. Elderly people needed medical support for longer than other age groups. Future earthquakes may be inevitable, but establishing arrangements for medical needs or making precautions for infectious diseases in shelters could reduce the effects of earthquake-related health problems.

A 70-year-old female underwent follow-up colonoscopy after colonic polypectomy. The colonoscopy revealed the presence of a 7-mm submucosal tumor in the sigmoid colon. The tumor surface was smooth and covered with normal mucosa. It was diagnosed as a submucosal tumor, and polypectomy was performed. Histopathological examination of the resected specimen revealed moderately to poorly differentiated adenocarcinoma measuring 2 × 5 × 3 mm with marked peritumoral lymphocytic infiltration and lymphoid follicle formation. It was diagnosed as carcinoma with lymphoid stroma (lymphoepithelioma-like carcinoma), SM (1,800 μm), ly2, v0, budding; grade 1. We confirmed the indication for noncurative additional surgical resection and performed laparoscopic sigmoid colectomy. No metastases were observed in the dissected lymph nodes.

PURPOSE We studied neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles in anesthetized patients. METHODS Fifty-four adult patients undergoing air-oxygen-sevoflurane-fentanyl and epidural anesthesia were randomly divided into orbicularis oris, corrugator supercilii, and adductor pollicis groups of 18 patients each. In the three groups, the degree of neuromuscular block caused by rocuronium 0.6 mg/kg was monitored at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles acceleromyographically. RESULTS Onset of neuromuscular block did not significantly differ among the three groups [157 ± 60, 186 ± 73, and 148 ± 45 s; mean ± standard deviation (SD)]. Minimum value of 1st stimulation in train-of-four (T1)/control at the corrugator supercilii group was significantly higher than in the orbicularis oris and adductor pollicis groups (0.108 ± 0.066 vs. 0.021 ± 0.024 and 0.002 ± 0.007; P < 0.001). T1/control at the orbicularis oris group was significantly higher than at the adductor pollicis group 30 min after rocuronium (P < 0.05). T1/control at the corrugator supercilii group was significantly higher than at the orbicularis oris and adductor pollicis groups 10-30 and 10-40 min, respectively, after rocuronium (P < 0.05). Train-of-four ratios at the orbicularis oris and corrugator supercilii groups were significantly higher than at the adductor pollicis group 40-120 min after rocuronium (P < 0.05). CONCLUSION The corrugator supercilii muscle is more resistant to rocuronium than the orbicularis oris and adductor pollicis muscles. Recovery of neuromuscular block at the orbicularis oris muscle is slower than that at the corrugator supercilii muscle but was faster than that at the adductor pollicis muscle.

症例は70歳，男性．排便時出血，肛門痛を主訴に来院，肛門部に2型腫瘍を認めた．腰椎麻酔下の腫瘍生検にて，小細胞癌（内分泌細胞癌）の診断となり，腹会陰式直腸切断術を施行した．病理組織学的所見では絨毛状高分化型腺癌に加えて，充実胞巣状に増殖する円形の腫瘍細胞を認め，CD56，chromogranin A，synaptophysinが陽性であり，内分泌細胞癌と診断された．術後補助化学療法としてFOLFOX4を6クール施行し，その後外来観察としたが，術後12カ月目にCTにて肺，肝転移が出現したため，mFOLFOX6を開始して現在経過観察中である．肛門管内分泌細胞癌は非常にまれであるが，極めて予後不良であり，手術単独では根治が難しく集学的治療が必要であると思われた．

左眼視力低下を初症状として再発を来した直腸癌の脈絡膜転移症例を経験したので，報告する．症例は49歳の男性で，直腸癌の根治手術15か月後に左眼視力低下を初症状として受診．眼底検査で左眼に，漿液性網膜剥離を伴う脈絡膜腫瘍を認め，胸部CTで両肺に空洞形成を伴う小結節影を多数認めた．経気管支肺生検で腺癌を検出したため，直腸癌の左脈絡膜転移，両側多発性肺転移と診断した．全身化学療法を施行した後，漿液性網膜剥離，網膜下の滲出性変化は改善，脈絡膜腫瘍は縮小し扁平化したが，視力の改善は得られなかった．一方，肺転移は次第に増悪，頸椎転移も出現し，再発後11か月で死亡した．結腸直腸癌の脈絡膜転移報告例は自験例を含め9例とまれであり，報告例は多臓器転移症例が多く，肺，肝転移から2次的に脈絡膜転移を起こす可能性が示唆された．

前側方の低位筋間痔瘻の治療法として，近年seton法が普及してきた．この方法は多くの長所が存在する反面，長い瘻管を有する痔瘻の全領域をsetonで離断すると瘢痕が大きくなり，治癒に長期間を要するという短所があった．この短所を解決すべく，我々は瘻管を分割して最小限の領域のみsetonで離断する手法を用いるようになった．初期にしばしば遭遇した再発症例の検討から，この瘻管分割の手法で再発を回避するには，以下の二つの条件を満足する必要があると考えられた．（1）原発口～原発巣をsetonで完全に離断できていること．（2）「原発口→原発巣→二次口」へと向かっていた排膿ルートが，「原発口→原発巣→瘻管分割部位直上のドレナージ部位」へ変換されていること．この（1）（2）の条件を満たす手技を確立して経験を重ねた結果，現在ではほぼ満足すべき成績が得られるようになった．

症例は53歳の男性．工事現場のコンクリートから突出した鉄筋の上に座り受傷した．その後肛門痛があったが軽度であったため3週間放置し，症状悪化後近医を受診，外傷性直腸損傷による直腸周囲膿瘍の診断にて当院紹介入院となった．入院時は肛門痛著明で歩行困難であり，脱水状態であった．直腸指診では直腸後壁側に半周性の直腸壁欠損があり，外傷性直腸穿孔の診断で，双口式人工肛門を造設し，直腸周囲膿瘍のドレナージ術を施行した．未治療の糖尿病があり，膿瘍の改善が不良で治療に難渋したが，直腸穿孔部が閉鎖していることを確認の上，術後7カ月後人工肛門を閉鎖した．杙創性直腸穿孔は通常受傷後直ちに治療される場合が多いが，経肛門的な直腸損傷の場合，症状が乏しい場合があり，本症例のように受診が遅れることがある．受診の遅延は治療の難渋につながり，合併症の頻度を高めるため，早期の診断，治療が予後の改善には重要である．

膵頭十二指腸切除後膵外瘻の低侵襲な内瘻化の試みはいくつか報告されているが，われわれはPEGを用いて，低侵襲に内瘻化しえた1例を経験したので報告する．症例は54歳，男性．十二指腸乳頭部癌にて亜全胃温存膵頭十二指腸切除施行．再建は胆管空腸，膵胃吻合とした．術後，膵胃吻合縫合不全に伴う胃十二指腸動脈出血があり，止血術施行．胃側の吻合口を閉鎖し，膵管チューブを外瘻にした．術後長期に栄養状態が不良であったため，再度の開腹手術を回避するため，残胃にPEGを造設し，膵外瘻チューブを胃瘻から残胃に挿入，膵液を消化管内に戻したところ，栄養状態が改善．そのまま，チューブを皮下に埋め込んで，内瘻化した．内瘻化後，3年経過したが，現在までチューブ閉鎖などのトラブルはなく，経過良好である．膵外瘻による栄養障害を伴う症例では，膵液を消化管内に戻し，栄養状態を改善してから内瘻化するという方法は安全で，有用であると思われる．

Gastrointestinal stromal tumor (GIST)の治療中に発生した,メシル酸イマチニブによると考えられる間質性肺炎を経験した。症例は82歳男性。消化管出血,腹腔内転移を伴うGISTに対し,メシル酸イマチニブの内服を開始し,原発巣,転移巣ともに著明な縮小を認めていた。内服開始35日目頃から労作時呼吸困難,咳嗽が出現し,38日目に入院した。胸部X線上広範囲のスリガラス状陰影を認め,急速に進行する高度の低酸素血症を示したため,同日人工呼吸管理とした。経過よりメシル酸イマチニブによる薬剤性間質性肺炎が疑われたため投与を中止し,メチルプレドニゾロン1g静注を3日間行ったところ,低酸素血症は改善した。その後,ステロイド内服下にメシル酸イマチニブを減量再開し,経過良好である。現時点でメシル酸イマチニブによる間質性肺炎の報告例は稀だが,使用に当たり十分な注意が必要と考えられた。

A 74-year-old Japanese woman presented with a 3-month history of anal bleeding. Proctoscopy revealed an unusual polypoid lesion with focal pigmentation at the dentate line, which was histologically diagnosed as a malignant melanoma. Whole-body clinical and radiographic evaluations revealed no alternative primary source. Endoscopic ultrasonography (EUS) showed well-delineated hypoechoic tumors invading the muscularis propria, and magnetic resonance imaging (MRI) revealed regional lymphadenopathy. Following this evaluation, an abdominoperineal resection with regional lymphadenectomy was performed. The excised tumor was histologically confirmed to be malignant melanoma, and its depth and metastatic lymph nodes proved to have been accurately and precisely evaluated by the preoperative examinations. Thus, EUS and MRI are useful preoperative diagnostic tools for the tumor staging of primary anorectal malignant melanomas, as for other rectal tumors.

GASTROINTESTINAL ENDOSCOPY 141 Current affiliation: Department of Academic Surgery (M9), Chiba University Graduate School of Medicine, Chiba, Japan. Reprint requests: Hiroshi Sashiyama, MD, Department of Academic Surgery (M9), Chiba University Graduate School of Medicine, 1-8-I, Inohana, Chuo-ku, Chiba, Japan No. 260-8670. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/54/125231 doi:10.1067/mge.2002.125231 Esophageal bronchogenic cyst successfully excised by endoscopic mucosal resection

To investigate cellular changes related to the malignant progression of keratinocytes, we studied the serum-resistant clones from CHEK-1, a human papillomavirus type 16 E6/E7-immortalized esophageal cell line cultured in a serum-free medium. Established clones exhibited morphologic variety. Slow growing clones presented in cuboidal shapes with tight cellular adhesion and highly expressed alpha2 and alpha6beta4 integrins. Moderately proliferating clones showed loose intercellular adhesion and reduced expression of alpha2 integrin. Spindle-shaped, rapidly proliferating clones with prominent actin stress fibers demonstrated reduced alpha6 and alpha4 integrin expression in addition to alpha2 integrin and showed anchorage-independent growth. Reduced expression of alpha2 integrin was observed between 50 and 100 population doubling lengths (PDLs) during the immortalization of CHEK-1. These results suggest that the reductions of alpha2 and alpha6beta4 integrins are related to changes seen during immortalization and malignant progression.

A 78-year-old Japanese female was admitted to our hospital with dysphagia and weight loss. An oesophageal tumour was demonstrated radiologically and endoscopically, and was diagnosed as oesophageal cancer by biopsy. Histologically, the resected tumour showed poorly differentiated squamous cell carcinoma with prominent lymphoid stroma and was diagnosed as the so-called lymphoepithelioma-like carcinoma (LELC). Epstein-Barr virus in the tumour was negative by polymerase chain reaction and in situ hybridization. Oesophageal LELC is extremely rare. The cases in the literature, as well as the one reported here, presented with gross features of a submucosal tumour-like appearance. Although the differentiation of the tumour cells is often poor, prognosis seems to be better than for other types of oesophageal cancer. Oesophageal LELC has characteristic clinicopathological features and should be classified by criteria independent of other types of tumour.

A 46-year-old Japanese man was referred to our hospital for treatment of an esophageal stricture. Esophageal cancer was suspected after detailed investigations, and a right transthoracic esophagectomy was performed. The resected specimen showed only nonspecific esophagitis with severe fibrous thickening in the submucosa, but no evidence of malignancy. Between 1906 and 1993, only 19 similar cases of benign esophageal strictures with fibrous thickening, excluding congenital and iatrogenic strictures, have been reported in Japan. These lesions occurred in the middle to lower third of the esophagus in 15 of 19 cases (78.9%), and 8 of the 19 patients (42.1%) were aged between 30 and 50 years. The interval between onset and hospital admission was short, being less than 1 year in 8 of the 12 patients for whom this information was available. Our patient demonstrated a disorder resembling the diffuse severe esophagitis described by Roth in 1974.

We studied neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles in anesthetized patients. Fifty-four adult patients undergoing air–oxygen–sevoflurane–fentanyl and epidural anesthesia were randomly divided into orbicularis oris, corrugator supercilii, and adductor pollicis groups of 18 patients each. In the three groups, the degree of neuromuscular block caused by rocuronium 0.6 mg/kg was monitored at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles acceleromyographically. Onset of neuromuscular block did not significantly differ among the three groups [157 ± 60, 186 ± 73, and 148 ± 45 s; mean ± standard deviation (SD)]. Minimum value of 1st stimulation in train-of-four (T1)/control at the corrugator supercilii group was significantly higher than in the orbicularis oris and adductor pollicis groups (0.108 ± 0.066 vs. 0.021 ± 0.024 and 0.002 ± 0.007; P

We studied neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles in anesthetized patients.Fifty-four adult patients undergoing air-oxygen-sevoflurane-fentanyl and epidural anesthesia were randomly divided into orbicularis oris, corrugator supercilii, and adductor pollicis groups of 18 patients each. In the three groups, the degree of neuromuscular block caused by rocuronium 0.6 mg/kg was monitored at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles acceleromyographically.Onset of neuromuscular block did not significantly differ among the three groups [157 ± 60, 186 ± 73, and 148 ± 45 s; mean ± standard deviation (SD)]. Minimum value of 1st stimulation in train-of-four (T1)/control at the corrugator supercilii group was significantly higher than in the orbicularis oris and adductor pollicis groups (0.108 ± 0.066 vs. 0.021 ± 0.024 and 0.002 ± 0.007; P0.001). T1/control at the orbicularis oris group was significantly higher than at the adductor pollicis group 30 min after rocuronium (P0.05). T1/control at the corrugator supercilii group was significantly higher than at the orbicularis oris and adductor pollicis groups 10-30 and 10-40 min, respectively, after rocuronium (P0.05). Train-of-four ratios at the orbicularis oris and corrugator supercilii groups were significantly higher than at the adductor pollicis group 40-120 min after rocuronium (P0.05).The corrugator supercilii muscle is more resistant to rocuronium than the orbicularis oris and adductor pollicis muscles. Recovery of neuromuscular block at the orbicularis oris muscle is slower than that at the corrugator supercilii muscle but was faster than that at the adductor pollicis muscle.

Two types of recombinant vaccinia viruses (VVs) expressing the env gene of the human T-cell leukemia virus type I (HTLV-I) were reported previously. One recombinant VV, WR-proenv1, synthesized the authentic env protein. In the other recombinant VV, WR-env17, the env gene was inserted within the signal sequence of the VV hemagglutinin (HA) gene, so that the reading frame for the env gene was in phase with that for the HA gene. Comparative studies were performed on the mode of expression and processing of the env proteins in relation to their immunogenicity. In WR-env17-infected cells, translation was initiated exclusively from the initiation methionine of the HA to produce nascently the chimeric env protein, including the altered HA signal peptide. Both this altered HA signal peptide and the internalized env signal peptide functioned as insertion signals for the endoplasmic reticulum. Although about half of the nascent chimeric protein was cleaved at the carboxyl terminus of the internalized env signal peptide to produce the authentic env protein, the other half was cleaved at the carboxyl terminus of the altered HA signal peptide alone to synthesize the chimeric protein. These events led to a less efficient transport of the env protein produced by WR-env17 from the rough endoplasmic reticulum to the Golgi apparatus than that of the authentic env protein synthesized by WR-proenv1. The efficiency of the processing and transport of the env protein affected the immunogenicity of these two recombinant VVs.

A novel gene transcript that is downregulated by HPV16 E6 protein was identified in mouse cells using differential hybridization and designated E6DG1. The cloned cDNA of E6DG1 was 1.3 kb in length and contained a small ORF potentially encoding a polypeptide of 45 amino acids. In vitro transcription and translation of E6DG1 cDNA resulted in a product of approximately 7 kDa and Western blot analysis using antibodies for E6DG1 peptide detected 7 and 14 kDa proteins. Downregulation of E6DG1 mRNA levels in cells expressing HPV16 E6 protein was observed at subconfluent cell densities, but not in confluent cells. Repression of E6DG1 protein enhanced the anchorage-independent growth and weakened the cell adhesion in Panc1 cells. Immunofluorescence analysis revealed the localization of E6DG1 within the nucleus. These results indicate that the E6DG1 protein may function in a signaling pathway related to anchorage-independent growth and adhesion control.

An alteration of the p53 gene function is a major factor in the development of esophageal cancer. Recently, p53 gene therapy has been applied for clinical studies in lung cancer and head and neck cancer. However, no preclinical studies have yet demonstrated an anticancer effect of adenoviral-mediated wild-type p53 gene therapy on esophageal cancer. We herein evaluated the effect of p53 adenoviral gene therapy on human esophageal squamous cell carcinoma to test the ability of clinical application. A normal esophageal epithelial cell line (EN53F) and two human esophageal cancer cell lines (ECGI-10 and T.Tn) with a p53 alteration were used. The transduction efficiency, p53 protein expression, p21 protein expression, the induction of apoptosis, and growth suppression were assessed by using the recombinant adenoviral vector Ad5CMV-p53. The transduction efficiency was 60%-80% at 100 plaque-forming units (PFU)/cell and 80%-100% at 300PFU/cell. A significant growth suppression following an Ad5CMV-p53 infection was observed in both cancer cell lines. A Western blot analysis confirmed the presence of both exogenous p53 protein expression and p21 protein induction. Apoptotic cell death was observed with TUNEL staining. T.Tn xenografts in nude mice transduced with Ad5CMV-p53 demonstrated significant growth suppression. These data suggest that Ad5CMV-p53 may thus be a potentially effective therapeutic agent for locally advanced esophageal cancer.

Transduction of human papillomavirus type 16 (HPV16) E6/E7 into primary culture of human esophageal keratinocytes using a recombinant adenovirus prolonged the life-span, while untreated cells senesced within 14-16 population doublings (PDLs). Up-regulation of telomerase activity and acquisition of serum-resistant growth were observed in the esophageal keratinocytes with extended life-span between 50 and 100 PDLs, and drastically increased after 100 PDLs. A keratinocyte sample with a polymorphism of Pro/Pro at codon 72 of p53 showed resistance to HPV16 E6/E7-induced life-span-extension and immortalization, in contrast to others with p53 polymorphisms of Arg/Arg or Arg/Pro, which did not. The high efficiency of E6/E7-induction by adenovirus vector also revealed the M1 and M2 stages of keratinocyte immortalization first described in this report.

A 69-year-old Japanese man presented with bilateral gynecomastia and a soft, mobile and clearly defined mass beneath the left nipple. A round radiopaque mass was revealed on mammography. The tumor was homogeneous, hypoechoic and measured 2.4X3.9 cm on ultrasonography. Based on a diagnosis of malignant lymphoma by needle aspiration cytology, a modified radical mastectomy with ipsilateral axillary lymph node dissection was performed. Malignant diffuse large B-cell type lymphoma was diagnosed histologically. Whole body examinations revealed no evidence of other tumors. Three courses of adjuvant CHOP therapy were subsequently performed. The patient is free of recurrence 12 months after surgery. Primary non-Hodgkin’s lymphoma (NHL) of the male breast is extremely rare. The occurrence of lymphoma in this patient could be related to elevated estrogen levels.